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Sun C, Wang Q, Li WT, Wen DN, Chen CH, Yang X, Shi W, Meng QH, Yao KH, Qian SY. Molecular characteristics and antimicrobial susceptibility of Staphylococcus aureus among children with respiratory tract infections in southwest China. World J Pediatr 2020; 16:284-292. [PMID: 31620982 DOI: 10.1007/s12519-019-00317-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 09/24/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND The molecular characteristics and antimicrobial susceptibility of Staphylococcus aureus (S. aureus) in general pediatric wards and county-level hospitals were rarely reported in China. METHODS Staphylococcus aureus was isolated from children hospitalized with respiratory tract infection (RTI) in Zhongjiang and Youyang counties in 2015. All isolates were typed by multilocus sequence, staphylococcal protein A, accessory gene regulator (agr), and staphylococcal cassette chromosome mec [SCCmec, for methicillin-resistant S. aureus (MRSA) only]. Polymerase chain reaction was used to screen 21 super-antigen (SAg) genes and panton-valentine leukocidin (pvl). Antimicrobial susceptibility testing was performed by E test. RESULTS A total of 2136 children were enrolled. Overall, 125 (5.9%) children carried S. aureus, among which MRSA accounted for 42.4%. ST59-SCCmec type IV-t437-agr group I (58.5%) was the most prevalent genotype in MRSA, and ST188-t189-agr group I (22.2%) was the top genotype in methicillin-sensitive S. aureus (MSSA). The pvl carriage rate in MRSA and MSSA was 15.1% and 9.7%, respectively (P = 0.4112). About 96.8% of S. aureus isolates were positive for at least one SAg gene. The most common SAg gene profile in the dominant ST59 clone was seb-sek-seq (42.8%). All S. aureus isolates were resistant to penicillin and erythromycin (minimum inhibitory concentration 90 was > 32 and 256 mg/L to penicillin and erythromycin, respectively), but usually susceptible to other tested non-β-lactam antimicrobials. CONCLUSIONS Staphylococcus aureus and MRSA were detected with a high frequency in children with RTI in county-level hospitals of China. ST59-SCCmec type IV-t437-agr group I was the dominant MRSA clone. The S. aureus isolates exhibited high resistance to penicillin and erythromycin.
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Affiliation(s)
- Chen Sun
- Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, NanLiShi Road 56, Xicheng District, Beijing, 100045, China
| | - Qing Wang
- Key Laboratory of Major Diseases in Children, National Key Discipline of Pediatrics (Capital Medical University), National Clinical Research Center for Respiratory Diseases, Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Wen-Ting Li
- Respiratory Department, Qilu Children's Hospital, Shandong University, Jinan, 250022, China
| | - De-Nian Wen
- Department of Pediatrics, People's Hospital of Zhongjiang County, No. 96 Da-bei Street, Deyang, 618100, China
| | - Chang-Hui Chen
- Youyang Hospital, The First Affiliated Hospital of Chongqing Medical University, People's Hospital of Chongqing Youyang County, Chongqing, 409899, China
| | - Xin Yang
- Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, NanLiShi Road 56, Xicheng District, Beijing, 100045, China
| | - Wei Shi
- Key Laboratory of Major Diseases in Children, National Key Discipline of Pediatrics (Capital Medical University), National Clinical Research Center for Respiratory Diseases, Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Qing-Hong Meng
- Key Laboratory of Major Diseases in Children, National Key Discipline of Pediatrics (Capital Medical University), National Clinical Research Center for Respiratory Diseases, Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Kai-Hu Yao
- Key Laboratory of Major Diseases in Children, National Key Discipline of Pediatrics (Capital Medical University), National Clinical Research Center for Respiratory Diseases, Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Su-Yun Qian
- Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, NanLiShi Road 56, Xicheng District, Beijing, 100045, China.
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Barcudi D, Sosa EJ, Lamberghini R, Garnero A, Tosoroni D, Decca L, Gonzalez L, Kuyuk MA, Lopez T, Herrero I, Cortes P, Figueroa M, Egea AL, Gagetti P, Fernandez Do Porto DA, Corso A, Turjanski AG, Bocco JL, Sola C. MRSA dynamic circulation between the community and the hospital setting: New insights from a cohort study. J Infect 2019; 80:24-37. [PMID: 31606351 DOI: 10.1016/j.jinf.2019.10.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 09/09/2019] [Accepted: 10/03/2019] [Indexed: 12/21/2022]
Abstract
Dissemination of methicillin-resistant-Staphylococcus aureus/(MRSA) is a worldwide concern both in hospitals [healthcare-associated-(HA)-MRSA] and communities [community-associated-(CA)-MRSA]. Knowledge on when and where MRSA colonization is acquired and what clones are involved is necessary, to focus efforts for prevention of hospital-acquired MRSA-infections. METHODS A prospective/longitudinal cohort study was performed in eight Argentina hospitals (Cordoba/ October-December/2014). Surveillance cultures for MRSA (nose-throat-inguinal) were obtained on admission and at discharge. MRSA strains were genetically typed as CA-MRSAG and HA-MRSAG genotypes. RESULTS Overall, 1419 patients were screened and 534 stayed at hospital for ≥3 days. S. aureus admission prevalence was 30.9% and 4.2% for MRSA. Overall MRSA acquisition rate was 2.3/1000 patient-days-at-risk with a MRSA acquisition prevalence of 1.96% (95%CI: 1.0%-3.4%); 3.2% of patients were discharged back to community with MRSA. CA-MRSAG accounted for 84.6% of imported, 100.0% of hospital-acquired and 94% of discharged MRSA strains. Most imported and acquired MRSA strains belonged to two major epidemic CA-MRSA clones spread in Argentina: PFGEtypeI-ST5-IVa-t311-PVL+ and PFGEtypeN/ST30-IVc-t019-PVL+. CONCLUSIONS CA-MRSA clones, particularly ST5-IV-PVL+ and ST30-IV-PVL+, with main reservoir in the community, not only enter but also are truly acquired within hospital, causing healthcare-associated-hospital-onset infections, having a transmission capacity greater or similar than HA-MRSAG. This information is essential to develop appropriate MRSA infection prevention-control programs, considering hospital and community.
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Affiliation(s)
- Danilo Barcudi
- Centro de Investigaciones en Bioquímica Clínica e Inmunología (CIBICI) CONICET and Universidad Nacional de Córdoba; Departamento de Bioquímica Clínica; Facultad de Ciencias Químicas; Haya de La Torre y Medina Allende, Ciudad Universitaria, X5000-Córdoba, Argentina
| | - Ezequiel J Sosa
- Instituto de Cálculo, Facultad de Ciencias Exactas y Naturales, Universidad de Buenos Aires, CONICET, Ciudad Universitaria, Pabellón 2, C1428EHA Ciudad de Buenos Aires, Argentina; Instituto de Química Biológica de La Facultad de Ciencias Exactas y Naturales (IQUIBICEN)-CONICET, Ciudad Universitaria, Pabellón 2, C1428EHA Ciudad de Buenos Aires, Argentina
| | - Ricardo Lamberghini
- Facultad de Ciencias Médicas, Universidad Nacional de Córdoba, Bajada Pucará 2025, X5000 Córdoba, Argentina; Hospital Guillermo Rawson, Bajada Pucará 2025, X5000 Córdoba, Argentina
| | - Analía Garnero
- Hospital de Niños de la Santísima Trinidad de Córdoba, Córdoba, Bajada Pucará 787, X5000 ANN, Argentina
| | - Dario Tosoroni
- Facultad de Medicina, Universidad Católica de Córdoba, Jacinto Ríos 555, X5004ASK Córdoba, Argentina
| | - Laura Decca
- Clínica Regional del SUD-Río IV, Av. Italia 1262, X5800 Río Cuarto, Córdoba, Argentina
| | - Liliana Gonzalez
- Hospital Infantil Municipal de Córdoba, Juan Antonio Lavalleja 3050, X5000 Córdoba, Argentina
| | - María A Kuyuk
- Hospital Militar Córdoba, Cruz Roja Argentina 1114, X5000 Córdoba, Argentina
| | - Teresa Lopez
- Hospital Guillermo Rawson, Bajada Pucará 2025, X5000 Córdoba, Argentina
| | - Ivana Herrero
- Hospital de Urgencias, Catamarca 441, X5000 Córdoba, Argentina
| | - Paulo Cortes
- Hospital Pediátrico del Niño Jesús, Av. Castro Barros 650, X5000HTT Córdoba, Argentina
| | - Myrian Figueroa
- Hospital Misericordia, Nuevo Siglo, Belgrano 1502, X5000 Córdoba, Argentina
| | - Ana L Egea
- Centro de Investigaciones en Bioquímica Clínica e Inmunología (CIBICI) CONICET and Universidad Nacional de Córdoba; Departamento de Bioquímica Clínica; Facultad de Ciencias Químicas; Haya de La Torre y Medina Allende, Ciudad Universitaria, X5000-Córdoba, Argentina
| | - Paula Gagetti
- Servicio Antimicrobianos, Instituto Nacional de Enfermedades Infecciosas (INEI)-ANLIS "Dr. Carlos G. Malbrán", Av. Vélez Sarsfield 563, C1282AFF Ciudad Autónoma de Buenos Aires, Argentina
| | - Darío A Fernandez Do Porto
- Instituto de Cálculo, Facultad de Ciencias Exactas y Naturales, Universidad de Buenos Aires, CONICET, Ciudad Universitaria, Pabellón 2, C1428EHA Ciudad de Buenos Aires, Argentina; Departamento de Química Biológica, Facultad de Ciencias Exactas y Naturales, Universidad de Buenos Aires, Ciudad Universitaria, Pabellón 2, C1428EHA Ciudad de Buenos Aires, Argentina
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- The members of the Study Group are listed in the Acknowledgments section, where the participants of each hospital and their affiliations are described
| | - Alejandra Corso
- Servicio Antimicrobianos, Instituto Nacional de Enfermedades Infecciosas (INEI)-ANLIS "Dr. Carlos G. Malbrán", Av. Vélez Sarsfield 563, C1282AFF Ciudad Autónoma de Buenos Aires, Argentina
| | - Adrián G Turjanski
- Departamento de Química Biológica, Facultad de Ciencias Exactas y Naturales, Universidad de Buenos Aires, Ciudad Universitaria, Pabellón 2, C1428EHA Ciudad de Buenos Aires, Argentina
| | - José L Bocco
- Centro de Investigaciones en Bioquímica Clínica e Inmunología (CIBICI) CONICET and Universidad Nacional de Córdoba; Departamento de Bioquímica Clínica; Facultad de Ciencias Químicas; Haya de La Torre y Medina Allende, Ciudad Universitaria, X5000-Córdoba, Argentina
| | - Claudia Sola
- Centro de Investigaciones en Bioquímica Clínica e Inmunología (CIBICI) CONICET and Universidad Nacional de Córdoba; Departamento de Bioquímica Clínica; Facultad de Ciencias Químicas; Haya de La Torre y Medina Allende, Ciudad Universitaria, X5000-Córdoba, Argentina.
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Gordon O, Cohen MJ, Gross I, Amit S, Averbuch D, Engelhard D, Milstone AM, Moses AE. Staphylococcus aureus Bacteremia in Children: Antibiotic Resistance and Mortality. Pediatr Infect Dis J 2019; 38:459-463. [PMID: 30239476 DOI: 10.1097/inf.0000000000002202] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Staphylococcus aureus (SA) is a major cause of bacteremia in children. Methicillin-resistant SA (MRSA) is considered a public health threat; however, the differences in the prognosis of children with methicillin-susceptible SA (MSSA) versus MRSA bacteremia are not well defined. METHODS Data from all SA bacteremia events in children (0-16 years) from 2002 to 2016 in a single Israeli tertiary center were collected. Positive cultures within 48 hours of hospitalization were considered community associated (CA). Those obtained afterward or from children hospitalized within the previous year were considered health-care associated (HA). RESULTS We recorded 427 events, 284 (66%) were HA, 64 (15%) were MRSA and 9 (2%) were CA-MRSA. There was no increase in MRSA during the study period. In-hospital, 30-day and 1-year mortality were 3% (12 cases), 3.5% (16 cases), and 12% (50 cases), respectively. A multivariable analysis controlling for demographics, admitting department and prior morbidity showed an increased 1-year mortality in children with HA bacteremia (hazard ratio [HR] 4.1; 95% confidence interval [CI]: 1.3-12) and prior chronic disease (HR 3.4; 95% CI 1.2 to 9.0). MRSA was not independently associated with increased one-year mortality compared with MSSA: HR (95% CI: 1.4 [0.6-3.1]). CONCLUSIONS Short-term pediatric mortality after SA bacteremia is low. HA-SA bacteremia has an increased long-term risk for mortality, particularly in children with chronic diseases. Our data suggest mortality was not increased for MRSA compared with MSSA bacteremia. The very low rate of CA-MRSA bacteremia justifies the current practice not to include glycopeptides in the empiric treatment of CA bacteremia in Israel.
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Affiliation(s)
- Oren Gordon
- From the Department of Clinical Microbiology and Infectious Diseases.,Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Matan J Cohen
- From the Department of Clinical Microbiology and Infectious Diseases.,Clalit Health Services, Jerusalem, Israel
| | - Itai Gross
- Department of Pediatric Emergency Medicine, Pediatric Emergency Medicine at the Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Sharon Amit
- From the Department of Clinical Microbiology and Infectious Diseases
| | - Dina Averbuch
- From the Department of Clinical Microbiology and Infectious Diseases.,Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Dan Engelhard
- From the Department of Clinical Microbiology and Infectious Diseases.,Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Aaron M Milstone
- Division of Infectious Disease, Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
| | - Allon E Moses
- From the Department of Clinical Microbiology and Infectious Diseases
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Prevalence of multidrug drug resistant organisms and hand hygiene compliance in surgical NICU in Cairo University Specialized Pediatric Hospital. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2018. [DOI: 10.1016/j.epag.2018.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Goldstein ND, Jenness SM, Tuttle D, Power M, Paul DA, Eppes SC. Evaluating a neonatal intensive care unit MRSA surveillance programme using agent-based network modelling. J Hosp Infect 2018; 100:337-343. [PMID: 29751022 DOI: 10.1016/j.jhin.2018.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 05/01/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Surveillance for meticillin-resistant Staphylococcus aureus (MRSA) in neonatal intensive care units (NICUs) is a commonplace infection prevention strategy, yet the optimal frequency with which to monitor the unit is unknown. AIM To compare various surveillance frequencies using simulation modelling. METHODS One hundred NICU networks of 52 infants were simulated over a six-month period to assess MRSA transmission. Unit-wide surveillance occurred every N weeks where N={1,2,3,4}, and was compared with the current NICU policy of dynamic surveillance (i.e. weekly when at least one positive screen, otherwise every three weeks). For each surveillance period, colonized infants received a decolonization regimen (56% effective) and were moved to isolation rooms, if available. FINDINGS As the surveillance frequency increased, the mean number of MRSA-colonized infants decreased, from a high of 2.9 (four-weekly monitoring) to a low of 0.6 (weekly monitoring) detected per episode. The mean duration of colonization decreased from 307 h (four-weekly monitoring) to 61 h (weekly monitoring). Meanwhile, the availability of isolation rooms followed an inverse relationship: as surveillance frequency increased, the availability of isolation rooms decreased (61% isolation success rate for four-weekly monitoring vs 49% success rate for weekly monitoring). The dynamic policy performed similar to a biweekly programme. CONCLUSIONS An effective MRSA surveillance programme needs to balance resource availability with potential for harm due to longer colonization periods and opportunity for development of invasive disease. While more frequent monitoring led to greater use of a decolonization regimen, it also reduced the likelihood of isolation rooms being available.
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Affiliation(s)
- N D Goldstein
- Department of Pediatrics, Christiana Care Health System, Newark, DE, USA; Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA, USA.
| | - S M Jenness
- Department of Epidemiology, Emory University, Atlanta, GA, USA
| | - D Tuttle
- Department of Pediatrics, Christiana Care Health System, Newark, DE, USA
| | - M Power
- Department of Infection Prevention, Christiana Care Health System, Newark, DE, USA
| | - D A Paul
- Department of Pediatrics, Christiana Care Health System, Newark, DE, USA
| | - S C Eppes
- Department of Pediatrics, Christiana Care Health System, Newark, DE, USA
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Ouyang J, Sun F, Feng W, Xie Y, Ren L, Chen Y. Antimicrobial Activity of Galangin and Its Effects on Murein Hydrolases of Vancomycin-Intermediate Staphylococcus aureus (VISA) Strain Mu50. Chemotherapy 2017; 63:20-28. [PMID: 29145175 DOI: 10.1159/000481658] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 09/19/2017] [Indexed: 11/19/2022]
Abstract
Backgroud: Antibiotic treatment for infections caused by vancomycin-intermediate Staphylococcus aureus (VISA) strains is challenging, and only a few effective and curative methods have been developed to combat these strains. This study aimed to investigate the antimicrobial activity of galangin against S. aureus and its effects on the murein hydrolases of VISA strain Mu50. This is the first report on these effects of galangin, and it may help to improve the treatment for VISA infections by demonstrating the effective use of galangin. METHODS Firstly, the minimum inhibitory concentration (MIC) and growth curve were used to investigate the antimicrobial activity of galangin against S. aureus. Secondly, transmission electron microscopy (TEM) was used to observe morphological changes of VISA strain Mu50. Thirdly, Triton X-100-induced autolysis and cell wall hydrolysis assays were performed to determine the activities of the murein hydrolases of Mu50. Finally, fluorescence real-time quantitative PCR was used to investigate the expression of the murein hydrolase-related Mu50 genes. RESULTS The results indicated that the MIC of galangin was 32 μg/mL against ATCC25293, N315, and Mu50, and galangin could significantly suppress the bacterial growth (p < 0.05) with concentrations of 4, 8 and 16 μg/mL, compared with control group (0 μg/mL). To explore the possible reasons of bacteriostatic effects of galangin, we observed morphological changes using TEM which showed that the division of Mu50 daughter cells treated with galangin was obviously inhibited. Considering the vital role of murein hydrolases in cellular division, assays were performed, and galangin markedly decreased Triton X-100-induced autolysis and cell wall hydrolysis. Galangin also significantly inhibited the expression of the murein hydrolase genes (atl, lytM, and lytN) and their regulatory genes (cidR, cidA, and cidB). CONCLUSIONS Our findings indicated that galangin can effectively inhibit murein hydrolase activity as well as the growth of VISA strain Mu50.
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Affiliation(s)
- Jing Ouyang
- Department of Pharmacy, Chongqing Public Health Medical Center, Chongqing, China
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Jackson KL, Mbagwu M, Pacheco JA, Baldridge AS, Viox DJ, Linneman JG, Shukla SK, Peissig PL, Borthwick KM, Carrell DA, Bielinski SJ, Kirby JC, Denny JC, Mentch FD, Vazquez LM, Rasmussen-Torvik LJ, Kho AN. Performance of an electronic health record-based phenotype algorithm to identify community associated methicillin-resistant Staphylococcus aureus cases and controls for genetic association studies. BMC Infect Dis 2016; 16:684. [PMID: 27855652 PMCID: PMC5114817 DOI: 10.1186/s12879-016-2020-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 11/11/2016] [Indexed: 12/25/2022] Open
Abstract
Background Community associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is one of the most common causes of skin and soft tissue infections in the United States, and a variety of genetic host factors are suspected to be risk factors for recurrent infection. Based on the CDC definition, we have developed and validated an electronic health record (EHR) based CA-MRSA phenotype algorithm utilizing both structured and unstructured data. Methods The algorithm was validated at three eMERGE consortium sites, and positive predictive value, negative predictive value and sensitivity, were calculated. The algorithm was then run and data collected across seven total sites. The resulting data was used in GWAS analysis. Results Across seven sites, the CA-MRSA phenotype algorithm identified a total of 349 cases and 7761 controls among the genotyped European and African American biobank populations. PPV ranged from 68 to 100% for cases and 96 to 100% for controls; sensitivity ranged from 94 to 100% for cases and 75 to 100% for controls. Frequency of cases in the populations varied widely by site. There were no plausible GWAS-significant (p < 5 E −8) findings. Conclusions Differences in EHR data representation and screening patterns across sites may have affected identification of cases and controls and accounted for varying frequencies across sites. Future work identifying these patterns is necessary. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-2020-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kathryn L Jackson
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Michael Mbagwu
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | | | - Daniel J Viox
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Emory University School of Medicine, Atlanta, GA, USA
| | - James G Linneman
- Biomedical Informatics Research Center, Marshfield Clinic Research Foundation, Marshfield, WI, USA
| | | | - Peggy L Peissig
- Biomedical Informatics Research Center, Marshfield Clinic Research Foundation, Marshfield, WI, USA
| | | | - David A Carrell
- Group Health Research Institute, Group Health Cooperative, Seattle, WA, USA
| | | | - Jacqueline C Kirby
- Department of Biomedical Informatics, Vanderbilt University, Nashville, TN, USA
| | - Joshua C Denny
- Department of Biomedical Informatics, Vanderbilt University, Nashville, TN, USA
| | - Frank D Mentch
- The Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lyam M Vazquez
- The Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Abel N Kho
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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